Effects of scenario‐based attribution on collective emotions and stigma toward persons with COVID‐19: A cross‐sectional survey

Abstract Background and Aims During this COVID‐19 pandemic, many people experience and share emotions such as fear, anxiety, sadness, anger, and disgust, which can be regarded as collective emotions. This study investigated the effects of scenario‐based attribution for serious diseases on collective emotions and social stigma. Methods Participants were 297 healthy adults who met two conditions: (1) not having tested positive for COVID‐19 (including their family members or close friends) and no experience of self‐quarantine; and (2) not having been diagnosed with lung cancer, and not having family members or close friends diagnosed with it. Three hundred participants were recruited, through a company conducting online surveys. A total of 297 data sets were analyzed, excluding data supplied by three participants who might have responded unreliably to the filler question. Scenarios were recorded according to attribution type (internal vs. external) and disease (COVID‐19 vs. lung cancer). A 2 × 2 factorial design was used, whereby participants were randomly assigned to one of four conditions. Results The COVID‐19 condition showed higher scores on the perceived risk and fear of the disease compared to the lung cancer one. The COVID‐19/internal attribution condition showed the highest scores for fear and anger toward scenario characters, and the lung cancer/external attribution condition showed higher sympathy scores than other conditions. Although attribution to COVID‐19 was not directly related to social stigma, it could evoke negative emotions toward infected people. Conclusion The findings suggest that attributions of serious diseases such as COVID‐19 to infected persons can influence collective emotions and the level of social stigma associated with the disease. Attention to the collective emotions and stigma associated with disease is a key component for communities and countries to recover from and respond to its impacts.


| INTRODUCTION
The global pandemic triggered by the spread of the coronavirus disease 2019 (COVID-19) has led to "collective emotions" such as fear, anxiety, sadness, anger, and disgust. 1 Collective emotions have been defined as emotions that are shared by a large number of individuals in a certain society 2 and/or as emotions felt by individuals as a result of their membership in a group or society. 3 Negative collective emotions not only induce psychological distress in the infected but also lead to stigma, social criticism, and discrimination.
These negative emotional responses and stigma can be influenced by attribution style, which is a method of reasoning that seeks to find the cause of one's own and other's behaviors and their consequences. 4 Attribution to the same event may depend on the actor's or observer's point of view, 5 which is called the actor-observer bias. 6 The actor-observer bias is described as the tendency to judge other's negative behavior (e.g., nonadherence to quarantine guidelines) more harshly than one's own negative behavior. 7 Because it is highly likely to be attributable to internal attributes such as the actor's personality, moral responsibility, attitude, and characteristics (i.e., internal attribution) and people have little prior knowledge of an actor's life experiences or typical behavior and situational forces in the observer's point of view. 7 In a study by Mantler et al. 8 participants read a brief description of a male with a serious disease (i.e., HIV/AIDS vs. lung cancer) and rated their controllability, responsibility, and blame for the disease. Regardless of disease type, controllability, responsibility, and blame were higher in the condition of internal attribution than in external attribution, which could be associated with the actor-observer attribution bias. These results showed that internal attribution to the disease can lead to blame being placed on and stigma associated with the person with the disease.
According to the risk assessment hypothesis, perceived risk can influence fear and lead to discriminatory behavior toward the person with the disease, irrespective of the type of attribution to the cause of the disease. 9 Previous studies 8,10 showed that the stigma associated with HIV/AIDS was significantly higher than for tuberculosis (TB) and severe acute respiratory syndrome (SARS) and the correlation between attributions (i.e., controllability, responsibility, and blame) and stigma was significant. The attribution model, including the sequential paths from controllability through responsibility and blame, to public stigma, was supported across HIV/AIDS, SARS, and TB. 10 However, the public perceived that people with HIV/AIDS were more responsible and blameworthy than those with other infectious diseases. TB and SARS are more infectious but treatable compared to HIV/AIDS, whereas the latter is more lethal and has a negative image related to moral responsibility, so the fear of HIV/AIDS infection and the likelihood of infection through simple contact can be overestimated. 10 Uncertainty over information about the disease and repeated exposure to the media leads to an overestimation of the risk of infectious diseases and causes anxiety, panic, and social stigma. 11 It is hypothesized that this will be applied to the early stages of COVID-19, wherein uncertainty is very high.
The purpose of this study was to investigate the effects of attribution to COVID-19 infection on collective emotions and social stigma, based on the determinants propounded by Mantler et al. 8

and
Mak et al. 10 Specifically, four types of scenarios were recorded according to the disease (COVID-19 vs. lung cancer) and attribution (internal vs. external). 8 Lung cancer is a respiratory disease similar to COVID-19, and an individual's lifestyle and behavioral habits such as smoking are closely related to the onset of lung cancer, indicating a higher perceived stigma than for other types of cancer. 12,13 Therefore, it was set as a comparative condition. In this study, as a collective emotion, emotional response was defined as "sympathy" toward the person with the disease, in addition to negative emotions such as fear and anger toward the person with the disease. In addition, as the COVID-19 pandemic continued, the fear of the disease itself was also measured.

| Participants
Participants were adults aged 18 years or older who met two conditions: (1) not having tested positive for COVID-19 (including their family members or close friends) and no experience of selfquarantine; and (2) not having been diagnosed with lung cancer, and not having family members or close friends diagnosed with it.
Three hundred participants were recruited nationwide in proportion to the distribution of the Korean population census, through an online survey company (http://www.invight.co.kr), and randomly assigned to one of four scenarios, that is, COVID-19/ internal attribution (

| Dependent variables
Attribution of the disease The "attribution of the disease" scale 10 was translated into Korean and modified to include COVID-19 and lung cancer scenarios by the authors of this study. Participants were asked how much they agreed on the cause of the disease in terms of controllability, responsibility, and blame in the scenario. The participants were asked to respond on a 6-point Likert scale ranging from 1 (strongly disagree) to 6 (strongly agree). Higher scores indicated greater internal controllability, personal responsibility, and more blame for the disease associated with people infected with COVID-19 or lung cancer.

Perceived risk of the disease
The Perceived Risk Scale 27 was modified and used for COVID-19 and lung cancer in this study. Participants were asked to respond, on a 7point Likert scale ranging from 0 (not at all) to 6 (strongly agree), to two questions about the severity of the impact and potential risk of the disease to themselves and their families. The internal consistency of the study was 0.88.

Fear of the disease
With reference to SARS-related studies, 19 this study used five questions measuring the fear of COVID-19 or lung cancer (e.g., "I am afraid I will get COVID-19 or lung cancer" or "I am afraid my family will get COVID-19 or lung cancer"). Participants were asked to answer on a 4-point Likert scale ranging from 0 (not at all) to 3 (strongly agree). The internal consistency of the present study was 0.84.

Emotional responses toward the scenario character
Emotional responses toward the scenario character were measured using a total of 10 items composed of adjectives expressing fear, anger, and sympathy. The "fear" subscale was measured by threatened, terrified, and scared, and the anger subscale was measured by aggravated, angered, and irritated, which were part of the Attribution Questionnaire-27 (AQ-27). 28 A "sympathy" subscale was added to reflect the preliminary survey on feeling sympathy for the scenario character, which included adjectives such as sympathetic, sorry, pitiable, and compassionate. Participants were asked to respond to all questions on a 4-point Likert scale ranging from 0 (not at all) to 3 (strongly agree). In this study, emotional responses were measured before and after the scenario presentation. The pre- The internal consistencies of this study were 0.93, 0.77, and 0.83 for each subscale, respectively.    Table 1 shows that there were no significant the differences between four conditions for all sociodemographic variables, anxiety as measured by the GAD-7, subjective health status, knowledge about the disease, and internality, chance and powerful others as measured by the locus of control (all ps > 0.05). Table 2 presents comparisons of internal attribution (controllability, responsibility, and blame) scores between four conditions.

| Comparisons of internal attribution
The responsibility score in the COVID-19 condition was significantly higher than that in the lung cancer condition (p < 0.05) but the difference in controllability and blame scores between the two conditions was not significant. The internal attribution condition showed significantly higher scores of controllability, responsibility and blame than external attribution (all ps < 0.001).
Only the interaction effect of disease×attribution for controlla-

| DISCUSSION
The purpose of this study was to examine the effects of COVID-19 on the collective emotions and stigma experienced by a community and its members. Participants read a scenario of a character with COVID-19 or lung cancer, and rated the attribution, perceived risk, fear of disease, emotional responses toward the scenario character, and stigma toward the disease from an observer's perspective.
First, when the character in the scenario became ill because of their actions and not due to external causes, the participants perceived the character to have control and therefore be responsible or blameworthy for the disease. These results are consistent with the actor-observer attribution bias. 5 Participants considered those with COVID-19 to be more responsible for their disease than those with lung cancer. In the internal attribution condition, COVID-19 was also T A B L E 2 Means, standard, and two-way ANOVA according to disease type and conditions of attribution in the scenario The results of excessive risk perception and fear of COVID-19 can be explained by the availability heuristic, that is, the phenomenon in which more easily imaginable events are perceived as more likely to occur, 38 and collective emotions. 39 The news media broadcasted the number of daily confirmed cases and deaths from COVID-19 and disclosed the route of the infections in confirmed cases. The public in the community was exposed to text messages (e.g., the number of daily confirmed cases in their local area) from local government agencies several times a day and would have perceived excessive the risk of being infected themselves by the availability heuristic. 38 As such, excessive exposure to information related to COVID-19 induced cognitive biases, which might have influenced the risk appraisal process 40  infection to be attributable to irresponsible behavior, which is partially consistent with the attribution theory. 44 Fear and anger toward the scenario character in internal attribution conditions increased further in the COVID-19 scenario, but sympathy toward the scenario character was higher in the lung cancer than in the COVID-19 condition. Moral responsibility is imposed on those diagnosed with COVID-19 and not following infectious disease prevention guidelines, thus increasing the possibility of anger toward the infected person 8 and fear associated with the need for self-protection. 43 If the disease is caused by an external factor, sympathy toward a person with the disease may increase in terms of the greater negative loss from lung cancer than from COVID-19. 44 Absolution from moral responsibility when the disease is due to an uncontrollable factor (e.g., biological cause) may also explain the increased sympathy for the person with the disease. 45 Finally, the stigma toward the scenario character was not  24 although coefficients of all subscales in our study were higher than 0.70. In future research, it will be necessary to use measurement tools with good reliability.
Second, the data for this study were collected at a time when the number of COVID-19 cases repeatedly rose and fell, so the public was still experiencing anxiety and fear of infection. Although respondents in which the participants, their family members, and close acquaintances had COVID-19 or lung cancer were excluded through the screening process, the ongoing COVID-19 pandemic may have affected the survey responses. So, fear and anger toward individuals with COVID-19 were greater than those with lung cancer, especially when disease was attributed to their misbehavior, even though lung cancer is a more fatal disease than COVID-19, at least in Korea. 27,28 It is necessary to conduct a replication study in the future after the pandemic comes to an end. Third, this study was cross-